Periodic Reporting for period 1 - TAMMIE (TAckling Multiple forms of Malnutrition In Ethiopia amongst women of reproductive age and children under five)
Période du rapport: 2023-01-01 au 2024-12-31
Increasing evidence shows that undernutrition and overweight/obesity co-exist, affecting countries, households, and individuals, a phenomenon known as the ‘double burden of malnutrition’ (DBM). It has been recognised as a public health problem in Sub-Saharan Africa, requiring double-duty actions (DDAs) – interventions addressing all forms of malnutrition simultaneously. Despite impressive progress in reducing undernutrition, Ethiopia still has one of the highest rates globally, which coincides with a rising problem of overweight/obesity, particularly in urban areas. Nevertheless, funding for interventions remains focused on undernutrition. Shifting policies and programmes to address multiple forms of malnutrition requires a good understanding of the problem, the current policy/programme environment, and stakeholders’ views on the nature of the problem and potential ways of addressing it. Unfortunately, such evidence is scarce. Therefore, the TAMMIE project (TAckling Multiple forms of Malnutrition In Ethiopia amongst women of reproductive age (WRA) and children under five (U5)) assessed the DBM to develop an intersectoral roadmap for action to tackle multiple forms of malnutrition. For this, a 4P cycle (Problem, Policies/Programmes, People, Priority) was used, with each ‘P’ constituting a distinct work package. The DBM is multifaceted and complex, so an interdisciplinary and mixed-method approach was used, drawing on insights from diverse disciplines (e.g. epidemiology, nutrition, public health, social sciences, and policy science) and methodologies (e.g. systematic review, Photovoice, social network analysis, and multi-criteria mapping). The specific research objectives (RO) are listed hereafter: RO1: To synthesise quantitative evidence on the shared drivers of the DBM in low- and middle-income countries (LMICs) and qualitative evidence on the drivers of unhealthy diets in Ethiopia; RO2: To collate evidence on the content of policies/programmes and the enabling environment (i.e. the environment that helps policy development and implementation) that aim to address different forms of malnutrition in Ethiopia; RO3: To map out the key people and organisations who are involved in these policies and programmes; and RO4: To gather perceptions of diverse stakeholders on priorities, gaps, and opportunities to prevent the DBM in Ethiopia.
So far, the project has made significant progress towards its objectives. Primary data collection and analyses have been completed for all work packages. Results are being synthesised for dissemination to the scientific community, decision-makers, and the public.
The problem domain (RO1) included two components: i. a systematic review that synthesised recent quantitative evidence on the shared drivers of the DBM in LMICs (n=77 articles from > 90 countries; 1 million participants), and ii. participatory photography (Photovoice) to explore the perceived challenges of - and solutions for - achieving healthy diets among WRA and their children U5 in urban Ethiopia (n=31 participants in five focus group discussions).
The policy domain (RO2) assessed i. whether existing national nutrition-relevant policies and programmes (n=80) align with recommended DDAs across four sectors (agriculture/food system, education, health, social protection), and ii. determined how the enabling environment could be strengthened to enhance the implementation of the recommended DDAs.
For the people domain (RO3), the Net-Map method was used to map stakeholders/institutions that develop or advocate for nutrition policies/programmes and could be candidates to promote DDAs. Maps were produced through multi-stakeholder, consultative focus group discussions (n=2, ~10 stakeholders/group).
For the priority domain (WP4), an online prioritisation survey was completed by various decision-makers working in Ethiopia (n=45). Four criteria (cost, feasibility, social acceptability, impact) were used to rank ten recommended DDAs. The top five ranked DDAs (maternal nutrition, breastfeeding, anthropometric monitoring, nutrition-sensitive agriculture, and school feeding) were retained and further appraised by diverse national-level stakeholders (n=20) using a mixed-method decision-analysis (Multi-Criteria Mapping).
The problem domain (RO1) included two components: i. a systematic review that synthesised recent quantitative evidence on the shared drivers of the DBM in LMICs (n=77 articles from > 90 countries; 1 million participants), and ii. participatory photography (Photovoice) to explore the perceived challenges of - and solutions for - achieving healthy diets among WRA and their children U5 in urban Ethiopia (n=31 participants in five focus group discussions).
The policy domain (RO2) assessed i. whether existing national nutrition-relevant policies and programmes (n=80) align with recommended DDAs across four sectors (agriculture/food system, education, health, social protection), and ii. determined how the enabling environment could be strengthened to enhance the implementation of the recommended DDAs.
For the people domain (RO3), the Net-Map method was used to map stakeholders/institutions that develop or advocate for nutrition policies/programmes and could be candidates to promote DDAs. Maps were produced through multi-stakeholder, consultative focus group discussions (n=2, ~10 stakeholders/group).
For the priority domain (WP4), an online prioritisation survey was completed by various decision-makers working in Ethiopia (n=45). Four criteria (cost, feasibility, social acceptability, impact) were used to rank ten recommended DDAs. The top five ranked DDAs (maternal nutrition, breastfeeding, anthropometric monitoring, nutrition-sensitive agriculture, and school feeding) were retained and further appraised by diverse national-level stakeholders (n=20) using a mixed-method decision-analysis (Multi-Criteria Mapping).
TAMMIE is timely and fits perfectly within the current nutrition debate as it addresses malnutrition in all its forms as one challenge that needs to be addressed holistically. TAMMIE adds to current evidence as it goes beyond purely focusing on the extent/causes of the DBM (i.e. problem) but also focuses on the enabling environment, i.e. policies/programmes, people and priorities that build and sustain momentum to implement actions that reduce the DBM.
Overall, there was good evidence of policy efforts focused on: i. improving diets and malnutrition in all its forms, and ii. enhancing and sustaining a positive enabling environment for effective nutrition policy development and implementation. Furthermore, the most promising interventions for tackling the DBM in Ethiopia were breastfeeding, followed by maternal nutrition and nutrition-sensitive agriculture. In contrast, anthropometric monitoring and school feeding were identified as the least effective interventions. Stakeholders, including decision-makers and women of reproductive age, discussed extensively the barriers at government, community, and individual levels that prevent the delivery and uptake of these interventions. At the government level, key barriers included financial constraints, limited access to technology, lack of diversity in production, land and water scarcity, and the impacts of climate change. At the community level, challenges encompassed limitations within health facilities, inefficiencies in service delivery, and constraints faced by health professionals. At the individual level, barriers included low maternal education levels, inadequate nutrition knowledge, time and financial constraints, and the influence of misconceptions or cultural beliefs. Finally, TAMMIE identified the key people that need to be leveraged and the conflicts that must be overcome to implement these interventions successfully. These insights are crucial for shaping the intersectoral roadmap for action to tackle the DBM in Ethiopia.
Overall, there was good evidence of policy efforts focused on: i. improving diets and malnutrition in all its forms, and ii. enhancing and sustaining a positive enabling environment for effective nutrition policy development and implementation. Furthermore, the most promising interventions for tackling the DBM in Ethiopia were breastfeeding, followed by maternal nutrition and nutrition-sensitive agriculture. In contrast, anthropometric monitoring and school feeding were identified as the least effective interventions. Stakeholders, including decision-makers and women of reproductive age, discussed extensively the barriers at government, community, and individual levels that prevent the delivery and uptake of these interventions. At the government level, key barriers included financial constraints, limited access to technology, lack of diversity in production, land and water scarcity, and the impacts of climate change. At the community level, challenges encompassed limitations within health facilities, inefficiencies in service delivery, and constraints faced by health professionals. At the individual level, barriers included low maternal education levels, inadequate nutrition knowledge, time and financial constraints, and the influence of misconceptions or cultural beliefs. Finally, TAMMIE identified the key people that need to be leveraged and the conflicts that must be overcome to implement these interventions successfully. These insights are crucial for shaping the intersectoral roadmap for action to tackle the DBM in Ethiopia.